Blake, Nancy PhD, RN; Leach, Linda Searle PhD, RN; Robbins, Wendy PhD, RN; Pike, Nancy PhD, RN; Needleman, Jack PhD
HEALTHY WORK ENVIRONMENTS (HWEs) have been associated with positive patient and nurse outcomes.1–3 Creating cultures of retention and fostering HWEs are 2 major challenges facing nurse leaders today.4 In the Institute of Medicine report, Keeping Patients Safe: Transforming the Work Environment of Nurses, concerns about organizational practices, work design, and organizational culture were identified.5 Recommendations to improve these problems included evidence-based staffing standards, the creation of interdisciplinary teams, and the establishment of visible and responsive nursing leadership.5
One reason registered nurses (RNs) leave their current position is to find better leadership.6 Historically, about 10% to 30% of new graduate RNs have left their current positions within the first 2 years.7 Research on organizational climate and intent to leave (ITL) among RNs showed that 17% of the adult critical care RNs sampled intended to leave their jobs within 1 year.8 Problems in the work environment are associated with retention issues. In addition, many studies have demonstrated a relationship between the work environment and medical errors.9–15 There are several types of medical errors, but the largest number of events is related to medication errors. Because many of the dosages are weight based in pediatrics, it is important that communication is good between the practitioners because there are few standard dosages. The Joint Commission reviewed 10 years of sentinel events and found that communication was the root cause in almost 70% of the errors.16
Communication and collaboration have been associated with nurses' attachment to their organization and improving nurse retention.9,17–19 For RNs, working in a hospital with a better practice environment has been found to be associated with significantly lower odds of experiencing burnout, job dissatisfaction, and the intention to leave.20 With an expected shortage between now and 2025 of more than 260 000 RNs, it is important to understand the relationship between HWEs, specifically communication, collaboration, and leadership, in order to improve retention.21 The shortage is expected to be twice as large as any other shortage seen in the United States in the past since the early 1960s. Nurses with pediatric intensive care unit (PICU) experience are hard to find, and hospitals are aggressively recruiting nurses away from each other. One study, conducted in 2000, estimated the cost to replace an RN was $42 000 for a medical-surgical nurse and $64 000 for a critical care nurse.22 These costs have increased significantly since that time. Recruiting costs and agency staffing that result from turnover are also costly to hospitals. In addition to increased costs, shortages at the unit level and higher nurse to patient ratios have been associated with poor patient outcomes and adverse events.10,23,24 Therefore, it is important for nurse leaders to manage retention of nurses in specialty areas such as PICUs and decrease nurse turnover in PICUs. A better understanding is needed of the relationship between communication, collaboration, and leadership in PICUs and ITL among PICU RNs. The purpose of this article is to present findings from an analysis of communication, collaboration, and leadership on ITL that was part of a larger research study of factors influencing the work environment of PICU nurses.25 The conceptual framework used for this study was the Donabedian26 structure, process, and outcome model.
HEALTHY WORK ENVIRONMENTS
Healthy work environments are those settings in which a nurse is able to be productive and provide good quality care and the nurse also has job satisfaction. Disch27 was one of the first nurse leaders to use the term “healthy work environment.” She defined an HWE as “a work setting in which policies, procedures, and systems are designed so that employees are able to meet organizational objectives and achieve personal satisfaction in their work environment.”27(p4) The original Magnet hospital studies were conducted to look at the environments in which the work setting was reported as being good and structures and processes were in place with good patient outcomes and strong retention.28 Researchers found good outcomes in these hospitals and examined the organizational structures that supported these units. The “ingredients” for magnetism that they found were nursing administration/leadership, professional practice, and professional development.28 In addition to these items, the follow-up studies on Magnet hospitals found empirical evidence for positive patient outcomes and nurse outcomes, as well as a supportive work environment for nurses.29–32 These Magnet environments were HWEs, although not labeled as such at that time. In 2005, the American Association of Critical-Care Nurses published 6 standards that make up an HWE. The HWE standards are skilled communication, true collaboration, effective decision making, authentic leadership, appropriate staffing, and meaningful recognition.33 Prior to the publication of these HWE standards, Heath et al1 did a validation of the literature on what constitutes an HWE. In that study, focus groups listed what they described could be found in an HWE. These characteristics of an HWE were collaborative relationships, caring practices, respect from colleagues, teamwork and “can do” attitudes, strong leadership with open communication and trust, and where their contributions are valued.1
Because PICU patients are critically ill, the complexity of their needs, the type of treatments that are used, and the stress to the families add additional challenges to communication among the health care team caring for these patients. It is important that team communication between nurses and physicians be timely and accurate.34 Numerous studies of nurses who work with adults have linked job satisfaction and ITL with the quality of communication in the work environment.9,17–19 Research findings showed that nurses were less likely to leave a job if they felt that there was good communication between the team.17 Another study suggested that nurses' intention to leave was related to the leader's style of communication.35
Several studies indicate that nurses and physicians communicate differently.36–39 In fact, nurses are frequently less satisfied with communication and interactions with physicians. The reasons for this include verbal abuse, lack of respect, or lack of teamwork. Other studies have shown a relationship between poor communication and poor patient outcomes.38,40–44 This reinforces the need for nurse leaders to improve the work environment in the PICU.
There are numerous studies in which nurses have reported poor collaboration that was associated with increased patient morbidity and mortality and nurse turnover.14,43,45–48 The Institute of Medicine report, Keeping Patients Safe, Transforming the Work Environment,5 recommended that collaboration be improved. Collaboration is a process in which health care professionals use joint decision making and communication.49 Attributes of collaboration include trust, mutual respect, knowledge, good communication, shared responsibility, and cooperation.50 Collaboration between RNs and MDs is a process to care for the needs of the patient and respect the unique abilities of each other as members of a larger multidisciplinary team. Collaboration must be in place at all times in an HWE. Collaboration between RNs and MDs has been shown to impact retention and ITL among nurses.40,43,46–48 In a large, multisite study in 42 ICUs across the United States and Canada, collaboration among caregivers in the intensive care unit (ICU) was significantly associated with lower nurse turnover.34
Leadership is one of the main factors that help reduce turnover and ITL among nurses in acute care hospitals. Numerous studies have linked leadership styles51–54 and participative governance15,55,56 to the desired outcomes of nurse satisfaction, commitment, and retention. Shirey and Fisher57 referred to leadership as all about people and relationships. To be effective, the nurse leader needs to champion the core values associated with leadership and model the behaviors that go with these core values.19 Wong et al54 found that authentic leadership is truly a guide to help build HWEs.
Authentic leaders work together with their coworkers and engage them in shared meaning.58 Research has revealed that the manager's leadership was an important variable for retention and quality of care in the unit, because it has a strong influence on the group's achievement of the unit's goals.59 A systematic review of the literature on leadership showed strong positive relationships between relational leadership practices, such as transformational leadership and staff nurses' intention to stay.60 One study concluded that the impact of authentic leadership spread beyond the unit level and has an impact on the profession, the health care delivery system, and the society at large.58
INTENT TO LEAVE
Intent to leave is the strongest predictor of actual turnover. Intention to leave has been defined as the employee's plan to quit his or her present job in the near future.61 Studies that have looked specifically at ITL have shown a relationship between nurses stating their intention to leave and their actual leaving/exit from their positions.17 Scientists studying social behavior have identified that intentions are the most immediate determinants of actual behavior.62–64 Findings from one study showed that nurses who intended to stay found their work environment far more favorable than those who intended to leave.64 There are numerous studies that support the work environment as the predominant factor that impacts nurses' decision to leave their current job.16,64–66 Intent to leave has not been studied in the PICU. A PICU is a stressful environment where nurses provide highly technical care for some of the most fragile children. Patients in the PICU range in age from newborn to young adult. Because physiological assessment parameters are significantly different in these age groups, additional competencies are needed by RNs to practice in this specialized area of critical care nursing. Critically ill pediatric patients have multiple diagnoses, and their acuity can require one-to-one nursing care. Accordingly, training programs for RNs in specialty units is very extensive. When a PICU nurse leaves, not only is it costly to the hospital but it is also very difficult to fill the open position with a pediatric critical care RN with similar experience. To maximize retention of PICU RNs, it is critical to know the factors that contribute to PICU nurses' intention to leave.
This study is a cross-sectional, correlational design. Nurses completed a survey questionnaire regarding their perceptions of communication, collaboration, and leadership in their current work environment and their intention to leave their current position.
Ten PICUs from different parts of the country participated in this study. Requests for participation went out to 35 PICUs across the United States. Twenty-eight agreed to participate, but 18 did not meet criteria. To reduce variation across units unrelated to study goals that might affect the outcomes, units asked to participate in the study were restricted to those with more than 10 beds and pediatric critical care medicine fellowship programs. Only 10 units met the criteria and could complete the institutional review board approval process within the time period that was necessary.
Population and sample
A convenience sample of the PICU RNs who worked in the study units for more than 6 months was used. A power analysis was done to determine the sample size. With an effect size set at 0.3, power at 0.8, and an α value of .05, a total of 352 RNs were needed with at least 35 RNs from each unit.
Instruments and measures
The Practice Environment Scale of the Nursing Work Index Revised (PES-NWIR) was used to measure the nurse practice environment. This scale was developed by Lake from the Nursing Work Index that Kramer and Hafner67 created from their work in measuring Magnet environments, which was later updated by Aiken and Patrician (NWIR).68 The PES-NWIR is a 31-item instrument used to measure the practice environment.69 The scale has 5 domains. They are nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability, leadership and support of nurses, staffing and resource adequacy, and collegial nurse-physician relations.69 It is a parsimonious tool that is brief and takes about 15 minutes to complete, using a 4-point Likert scale ranging from 1 (strongly agree) to 4 (strongly disagree). The mean scores for each subscale are figured, with a high score being favorable and correlating with an HWE.
The PES-NWIR was selected as a Nursing Performance Measure by the National Quality Forum in 2004. It has been validated in many populations of nurses and settings, including oncology, medical-surgical, and dialysis units.70 In 2006, the National Database of Nursing Quality Indicators began to offer the PES-NWIR as part of the nurses' annual satisfaction survey.71 The reported Cronbach α ranges from 0.80 to 0.96.69,72,73 The ICU Nurse-Physician Communication Questionnaire is a questionnaire used to measure 5 domains of communication in the ICU. These include within-group communication openness (RN-RN); between-group communication openness (RN-MD); within-group communication accuracy (RN-RN); between-group communication accuracy (RN-MD); and communication timeliness. Only 22 questions that are directly related to communication were used from this tool. These questions measured RN-RN and RN-MD communication. The ICU Nurse-Physician Communication Questionnaire had both consistency and reliability when measured among staff in the ICU and hospital emergency departments.74–76 Reliability and validity have been demonstrated among ICU physicians and nurses and in other populations of nurses and physicians.10,74–76 All but one of the domains, communication timeliness, indicated a good to high reliability using the Cronbach α of 0.7 as the accepted cutoff.74 Communication timeliness was at 0.6.
Demographic data were collected from RN participants. These demographic variables included were age, sex, education, experience in nursing, experience in pediatric intensive care nursing, as well as their intention to leave their organization.
Hospital- and unit-specific data were obtained as well as information regarding the nursing leadership structure, the medical leadership, the physician staffing and availability, and the type of hospital. In addition, whether the unit was pediatric or nonpediatric, Magnet or non-Magnet, or Beacon or non-Beacon unit was obtained. The Beacon unit designation is a designation of excellence in nursing and quality at the unit level and is awarded by the American Association of Critical-Care Nurses. Data about union representation, patient days, ownership of the hospital, and nursing hours per patient day (HPPD) for each unit were collected. The manager of the participating units provided these data.
Nurses' intention to leave was measured by one question in the demographic portion of the questionnaire. The question was “Do you intend to leave your job in the next six months?”
Before contacting eligible PICUs to participate, the UCLA institutional review board approved the study. Packets were mailed to nurse managers from different children's hospitals across the country, and they were approached to participate in this study. Six of the study sites also required institutional review board approval. Nurses were recruited via e-mail from the principal investigator. A small token was offered for completing the surveys in the form of a Starbuck's gift card. The surveys were accessed via the Internet, and the entire questionnaire was completed online. Questionnaires were anonymous, and confidentiality was maintained. A coding system was used to de-identify the participating hospitals. Data were collected regarding the patient outcomes for the previous quarter for each of the study units to get closely matched data regarding the patient and nurse outcomes and the work environment.
SPSS 17.0 was used to perform the statistical analysis. Descriptive statistics were obtained. The frequencies and percentages of responses from sites to the posttrial survey were quantitatively provided by SurveyMonkey (SurveyMonkey.com, Limited Liability Company, Palo Alto, California). Correlations to examine the relationships of the communication, collaboration, and leadership and nurses' intention to leave were analyzed. Multiple regression and 1-way analysis of variance were used to estimate models when significant correlations were found. The significance level for this study was .05. Collinearity diagnostics were also run for the dependent variable. The Cronbach α was determined for reliability of the instruments used. The Cronbach α for the PES-NWIR was found to be the same as others had found. The Cronbach α for the ICU Nurse-Physician Communication questionnaire was higher than that found by others and was above 0.8 in all domains.
A total of 415 completed surveys were obtained, and the overall response rate was 47%. Most participants were female (94%). The group was not ethnically diverse, with the majority of the participants being white (88%) and non-Hispanic (95%). A majority of participants had a BSN degree (75%) and were full-time employees (82%). Almost half of the sample was certified (46%) either in pediatrics or in critical care. Years in their current position ranged from 6 months to 40 years; most of them having less than 10 years of experience (80%), with the years of experience of the RNs ranging from 6 months to 45 years. The majority had less than 10 years of experience (65%). The demographic data are shown in Table 1.
TABLE 1-a. Participa...Image Tools
All of the PICUs in the sample were in freestanding children's hospitals affiliated with academic medical schools, and they all had PICU fellowship programs. Eight of 10 hospitals had American Nurses Credentialing Center Magnet designation, with 3 PICUs also having Beacon designation. The other 2 hospitals were interested in achieving Magnet designation and were on the journey to Magnet. The HPPD ranged from 19.2 to 22.85. The patient days in 2011 for these units ranged from 2000 to 15 720. In 6 of these units, the managers supervised only these units, whereas 4 of the units shared a manager with another unit. Nurses were represented by a union in 4 of the units. Nurse practitioners were part of the care delivery team in 8 of the 10 units (Table 2).
The scores for ITL were from 1 to 2, with a score of 1 being intention to stay in their current position and a score of 2 being leaving their current position for another one. The mean score was a 1.37, indicating that most wanted to stay in their current position. The overall mean score for collaboration was 3.30 on a 4-point scale, with the majority of nurses scoring their units high on collaboration. The mean score for leadership was 2.98 on a 4-point scale. The mean scores for communication ranged from 3.26 to 4.11 on a 5-point scale (Table 3).
Correlations for the main variables ITL, communication, collaboration, and leadership, as well as the demographic nurse and unit variables and hospital variables, were determined. Pearson correlations for these variables are shown in Table 4. There was a statistically significant correlation (0.709) between collaboration and open communication between groups (RN-MD), and no multicollinearity was found when collinearity diagnostics were run. To check for nonindependence of the variables used for the dependent and predictor variables, and the nesting effect of the individual nurse, intraclass correlations were obtained. Correlations were 0.129 to 0.488, reflecting some association but showing independence.
Findings show a statistically significant relationship between leadership and the outcome ITL but not any of the other predictor variables. None of the communication variables, timely, open, and accurate communication between RNs and among RNs and MDs, were significantly associated with PICU nurses' intention to leave, nor was collaboration significant to PICU nurses' intention to leave. However, years of experience as an RN had a statistically significant inverse relationship (P < .01) with ITL. No other RN characteristics were associated with ITL. The hospital variables HPPD, Magnet designation, union, and whether the manager is responsible for more than 1 unit showed no statistically significant association with ITL among the pediatric critical care nurses in this sample.
Multiple regression models were run to learn more about the relationship between predictor variables (communication, collaboration, and leadership) and the outcome or dependent variable ITL. Several models were tested, and 2 of the models were significant at the .05 level established for this study. While 2 of these models were significant, none of the models could account for more than 7% of the variability in ITL (Table 5).
TABLE 5-a. Multiple ...Image Tools
The models were first tested with the predictor variables collaboration, leadership, and the 5 domains of communication (see model 1 in Table 5). Because the percentage of variability (R2 = 0.029) was so low and the model was not statistically significant, different predictor variables were included for the second regression.
TABLE 5-b. Multiple ...Image Tools
Model 2 tested the relationship between leadership, communication timeliness, communication accuracy between RNs and between RNs and MDs, communication openness between RNs and between RNs and MDs, and nurses' intention to leave. This model was also not statistically significant at the .05 level. Because the first 2 models were not significantly associated with the main independent variables, demographic and unit variables were included in the next 2 models.
Model 3 included years of experience, leadership, and communication timeliness. This model was statistically significant (P < .01) but had an R2 value of 0.034 that predicts only 3% of the model change, which is very low. Additional models were run to find a model that could explain more than 10% of the variance, but no models met this level of prediction. There could be other predictors that were not measured in this study that could explain the variance, including commitment to the organization, recognition, identity, and pay.
Model 4 tested the relationship between communication, collaboration, leadership, years of experience, highest level of education, age, as well as Magnet designation, HPPD, and managerial supervisory responsibility for more than 1 unit. This model was statistically significant (P < .05) with an adjusted R2 value of 0.069, indicating that only 7% (R = 0.069) of the variance in ITL was predicted by all of these variables combined. This model revealed an inverse relationship between leadership and nurses' intention to leave, demonstrating that the stronger the leadership presence and perceived leadership support nurses reported, the lower their intention to leave. As the variables of communication timeliness, communication openness between RNs and MDs, communication accuracy between RNs, HPPD, and age went up, the ITL score went down. Unfortunately, only 2 models were significant but none of them were strong enough to predict the relationships between the independent variables and the dependent variable ITL. Collinearity diagnostics were run for the dependent variable ITL, which showed multicollinearity was not present.
LIMITATIONS OF THE STUDY
There are several limitations to this study. It is a cross-sectional, descriptive design. Although the sample was representative of RN population, the majority of the nurses being female and white may influence the findings relative to communication and perceived leadership support. Because the sample was from only 10 PICUs, there is an increased risk of a type II error (failure to find significant relationships). The dependent variable and predictor variables (ie, Magnet designation, HPPD, and manager supervisor responsibility for >1 unit) were used for each nurse on a unit. This creates a clustering or hierarchy and that could have potentially created nonindependent observations in the regression analysis, although intraclass correlations indicated independence. However, sample bias might be present, as nurses who are more satisfied with their job may have been more likely to participate.
Nursing leadership was found as the most important factor related to low ITL and turnover in PICU nurses. Study findings support results reported in several other studies involving adult critical care nurses.7,77,78 Leadership is critical in optimizing the work environment and increasing retention for the PICU nurses. Because hospital structures are so complex and the care delivery processes are important for safe, effective, and efficient care, good leadership is necessary to optimize the work environment for bedside RNs. Support from unit-level nurse managers has a strong association with job satisfaction,51,66,79 which when combined with good communication and collaboration, increases patient safety and improves nurse and patient outcomes.20,66 It is important to PICU RNs that they have access to their nurse leaders and that hospitals work to decrease the number of units that one nurse manager oversees. Supportive relationships that empower frontline PICU nurses may enhance their ability to provide safe patient care and decrease turnover.6,59,78,79
In another analysis, when communication, collaboration, and leadership were present, significant associations with better patient outcomes were found.25 Although communication and collaboration were not predictive of ITL among PICU RNs, they are important in creating HWEs. Communication has been found to be important in nurse managers' engagement with their staff. Nurse managers' leadership and communication contribute in a vital way to HWEs. Nurses do not leave organizations, they leave their managers.80 Managers who feel supported by organizations, in turn, support their staff.
Many nurse managers are responsible for supervising more than 1 unit.57 In Ritter's review of the literature on healthy work environments, she found one study in which a manager had 71 direct reports.6 This is too many director reports for one manager to manage and still provide good leadership. In this study, 4 of the units had managers who supervised other units. There were no significant findings, though, regarding PICU nurse managers supervising more than 1 unit or not and ITL. Study findings did show a strong relationship between nursing leadership and nurses' intention to leave. With the complexity in the PICU, it is essential to have strong leadership that is visible and available to the staff. Therefore, it is vital to decrease nurse managers' workload in the PICU to maximize the effectiveness of their leadership and enable them to spend more time with frontline nursing staff.
A second finding in this study was that the more years of experience the nurses had, the less likely they would be to leave their current job. As nurses' seniority increased, their intention to leave was significantly lower. Pediatric ICU nurses in this study are modeling what has been found to be the case among many employees in other industries and consistent with findings in other studies.55 When employees are younger and less experienced, they tend to be more mobile and more apt to switch jobs than more experienced employees.
While communication and collaboration are important in creating HWEs, they were not as important in decreasing turnover in this study. Communication accuracy between RNs showed an inverse relationship with ITL in the regression models, but it was not significantly related. This could have been because the overall mean scores were high in these areas (3.26 of 5). The highest communication score mean was in communication openness between RNs (4.11 of 5). Although it was expected that both communication and collaboration would influence ITL among PICU RNs, this was not the case.
Findings from this study indicate that effective nursing leadership is important to PICU RNs and significantly influences their decisions about staying in their current job. This underscores the important role that the critical care nurse manager has in fostering retention of pediatric critical care RNs and contributing to the quality of the work environment in PICUs. The leadership abilities of the ICU nurse manager are particularly valuable not only because of the expected, serious shortage of health care professionals, particularly those in specialty, high-technology areas, but also because effective nurse leaders who produce high retention save their hospitals thousands of dollars in recruitment and replacement costs.
One cannot discount the role of authentic leadership at the unit level. It is important that hospitals provide leadership training for first-line nurse managers so that they can support the work of frontline staff at the bedside. Further research is needed to find out from RNs what they value in their leaders that keep them in their job. To decrease turnover and ultimately decrease hospital costs related to new employee orientation, training and use of temporary staff, a continued focus on building and supporting strong leadership at the unit level in hospitals is needed.
Research that further explores how the leadership behavior of nurse managers directly impacts retention/ITL and to what extent leadership development for these nurse managers can improve their relationships as leaders with bedside RNs is recommended. Future research is needed to determine whether there are other variables that could account for the variance, including pay, benefits, commitment to the organization, and recognition. The results of this study are useful to hospital administrators working to decrease turnover and are particularly useful to chief nurse executives and nurse managers of PICUs so that they can focus their efforts on what matters to frontline nurses and use empirical evidence to support their decisions in doing so.
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collaboration; communication; healthy work environment; intent to leave; leadership; nurses' work environment